Over the last 30 years we have seen an increase in both quantity and quality of research regarding the use of anabolic androgenic steroids (AAS) and associated image and performance enhancing drugs in the United Kingdom. However, there is a clear need to develop the evidence base.

The National Institute for Health Research (NIHR) recognises this need and ultimately to answer the question: What is the evidence to establish effective interventions to reduce image & performance enhancing drugs (IPEDs) related harms?

In response to a call for an NIHR Development Award in relation to the IPEDs evidence base, a research partnership was established and was successful in gaining this award.

This ambitious short-term project can be summarised in the work packages below:

Central to this research is the research partnership’s existing networks, for consultation to generate robust prevalence estimates (building on existing preliminary analyses) and to facilitate the collation of research evidence (including grey literature and planned outputs) and IPED service and intervention information and data. These findings will be used to engage with a range of stakeholders to generate a shared understanding of the actors and systems that influence issues related to IPED use.

This research will generate multiple, academic outputs and will result in public health impact in the short- and long-term. The findings will provide vital data to support applications to the call to evaluate the effectiveness of IPED interventions, planned by the NIHR for later 2021. The summary of research finings and gaps will inform this future research, while the IPED service and interventions data will aid the identification of suitable candidates for evaluation (and controls). Furthermore, the systems mapping will provide essential learning regarding the complex nature of choices and influencing factors related to IPED use.

To ensure rigour and the highest ethical and research standards we have appointed a study steering committee. Each member brings different expertise and experience to help guide the project to a successful conclusion.

The project started on 1st February 2021 and will run for six months. All work packages are well underway and making excellent progress, not least due to the support we have received from members of the ASUK network. While there is a huge amount of work across the work packages, as illustrated below we have a clear vision of how the research will come together and the findings will be disseminated. This Network will be an essential element in the successful delivery and dissemination of the work.

People with lived experience of IPED use have been involved since the inception of this call and will be essential to the research delivery, production of meaningful outputs and their dissemination. Input from those with “real-world” experience and knowledge of IPEDs and the gym communities have influenced the focus and design of this work including providing feedback and advice on draft applications and protocols. This community engagement and influence has now been formalised within the structure of the Public Expert Advisory Board

A brief interim report will be provided to NIHR at the end of April. This will include an update on progress, highlighting of barriers and any changes to the planned delivery. We will use this information to update ASUK member in our May Newsletter.

Work Package 1

Referred to as ASSESS (Anabolic Androgenic Steroid Use Population Size Estimation: First Stage Study), the aim is to better understand the likely range of the size of the population using AAS and the extent that this varies geographically, so as to inform future estimation work. In preparation for WP1, the research partners have collaborated with Public Health Wales and NHS Scotland to conduct extensive unfunded preliminary work towards estimating the prevalence of AAS use in the UK.

This unfunded work is utilising available data from Wales, Scotland and England, including publicly available data (e.g. Crime Survey), data obtained from service monitoring (NSP data were available have been accessed), obtained through data request (e.g. Crimestoppers) and research projects (held by the research team and from literature searches). These are being used to generate a range of possible estimates of the size of the AAS using population (e.g. by using multiplier approaches).

The WP will refine the methods and assumptions used:
A. to produce local/regional estimates of the size of the AAS using population

B. for aggregating these local estimates to generate an estimate of the likely range of the national population size

C. to then refine the likely range and explore appropriate methods for use in future estimation approaches and data needs.

Invited experts will join the ASSESS Delphi panel. Feedback and ratings from each Delphi wave will be analysed with estimates and methods refined or discounted prior to subsequent rounds. It is anticipated that after the first round, at least two further rounds will be required to generate a likely size range of the AAS using population and to gain broad consensus on this, however there is sufficient flexibility for an additional ASSESS Delphi round to be incorporated within the time frame of this project.

Work Package 2

WP2 will map UK-led IPED research outputs since 2015, using a scoping review methodology underpinned by the general research question “what do we know about UK based research on IPEDs”. We will generate a comprehensive listing of MESH terms to guide the search (2015 to date) which will be conducted on the following databases: Web of Science; Cochrane Library; MEDLINE; PsycINFO; SPORTDiscus; Social Science Citation Index; Conf Proceedings Citation index; PubMED; Science Direct; and Researchgate. To enable the broadest picture of current knowledge and perceptions relating to recent IPED research in the UK, we will include academic and grey literature spanning policy documents and reports, online reports, conference proceedings, commentary pieces, and editorials, in addition to peer reviewed research articles.

This search will be strengthened by the inclusion of articles identified in recent literature reviews of the IPEDs evidence-base carried out by the research team. Members of the ASUK Network will be provided with the draft publications list and asked for any academic and grey literature that may be missing and for any articles in press or other relevant material.

The inclusion and exclusion criteria for the study will be discussed and agreed with all members of the research team. Duplicates and irrelevant records will be removed, included records will be charted according to features of the research such as study population, specific IPEDs, interventions and types of data collected to facilitate the identification of the breadth and depth of the evidence base and of current gaps in knowledge

Work Package 3

Mapping of current interventions for users (or those contemplating the use) of IPEDs. This will include details of service provision, aims and objectives, interventions, professional skill mix, data collected, funding mechanism, permanence of service and key data elements to support NIHR effectiveness evaluation call in 2021. All relevant data are in the public domain and support for collection and collation of information will be sought from key practitioners and service managers within ASUK Network. It is anticipated that needle and syringe programmes (NSPs) will be the major providers of services for this group and in the absence of a robust national monitoring system of provision, the support of ASUK members will be invaluable. The findings, in the form of a directory of interventions for people who use or who are contemplating the use of IPEDs will be made available on the ASUK website for the benefit of all stakeholders including practitioners, researchers and people who use (or may use) IPEDs. We aim to ensure that this scoping of the nature and characteristics of services and interventions in addition to their distribution will lead to the development of quality standards for service provision.

Work Package 4

The key aim of this work will be the identification of the key factors that may influence decisions to use IPEDs. In particular the research will look to identify influencing factors related to higher risk behaviours associated with IPED use. The work will incorporate a broad approach to potential influences including the role of individuals, organisations, concepts and environmental factors. While this approach has been successful in relation to other public health concerns this is novel to the field of AAS and associated IPEDs.

The main output of this study will be a ‘systems’ map of the influences upon IPED use. The map will be created during workshop 1 with participants and subsequently further developed by the research team. This will be presented at workshop 2, and further developed during and following the workshop. The refined version will be disseminated to participants approximately for further input and comments.

Work Programme 5

Alongside these important research topics we need to develop the mechanisms to disseminate the emerging IPED evidence base. The dissemination strategy, including non-academic, targeted outputs for practitioners and IPED users will assist in facilitating a better understanding between these diverse stakeholder groups. Demonstrating clear findings, together with how they were generated will result in a shared understanding and appreciation of service development and potentially overcome barriers to engagement.

We hope that this website, www.anabolicsteroids.org.uk and associated network will act as an effective mechanism for dissemination of findings to academics, practitioners and the communities they serve.